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Name:

Date Of Birth:

Address:

City, State:

Zip Code:

Home Phone:

Cell Phone:

Work Phone:

Email:

Do you prefer email or text Appointment Reminders?

Sex:

Martial Status:

Employer:

Occupation:

Primary Care Physician:

Phone:

Vision Plan

Subscriber's Name:

ID#:

Relationship to patient:

Subscriber's Date of Birth:

Subscriber's Address (if different than above)

Medical Insurance:

Subscriber's Name:

ID#:

Relationship to patient:

Subscriber's Date of Birth:

Subscriber's Address (if different than above)

Emergency Contact Person​​​​​​​

I grant permission to share my medical information with this contact.
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Name:

Number:

Relationship:

Privacy Policy

I hereby acknowledge that I have received a copy of the Lori A. Heyler, OD LLC ‘s Notice of Information Practices and I understand that the notice describes how this office uses and discloses my medical and billing information.
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Signature:

Date:

Assignment of Insurance Benefits​​​​​​​

I hereby authorize payment directly to Lori A. Heyler, OD LLC from my vision plan and/or health insurance. I understand that I am responsible for charges not covered by my insurance.
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Signature:

Date:

admin none 10:00 AM - 07:00 PM 09:00 AM - 05:00 PM 09:00 AM - 05:00 PM 09:00 AM - 05:00 PM 09:00 AM - 01:00 PM By Appointment Only Closed